When something goes wrong with a patient or a med

The tube came out while you were giving care

A tube came out mid-turn. Your note is the version of those minutes everyone reads later, so write it so they can be rebuilt.

10 min read built on 5 full opinions updated 2026-10-22

Written by a med-surg RN, ten years, day shift. Why there is no name on it · How this guide is made

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You were bathing, turning or moving a patient, and a trach, ET tube, feeding tube or drain came out. You handled it. Now you have to chart it. Someone who wasn't in the room should be able to read your note and rebuild those minutes in order: what you were doing, who had hold of the device, what you saw first, what you did, who you called, and how the patient responded.

Key points

  • Write what you were doing at that moment and who had hold of the device. If nobody did, write that.
  • Write what you saw first, the way you saw it. Leave the cause out unless you watched it happen.
  • List your actions in order and put a time on each one. Say where each time came from.
  • Name the provider you told, how you reached them (page, phone, in person), the time, and what they ordered.
  • Give numbers for the patient before, during and after: SpO2, HR, RR, color, work of breathing, responsiveness.

What to write

Trach, during a bath or turn

How it often gets written How it reads better
Trach came out during care. Replaced. Pt tolerated well.1412 turning pt to L side for linen change with CNA J. Ruiz. I was at the head holding the trach flange with my R hand. CNA was rolling the pt. On the roll, flange pulled free of my hand and the trach came fully out of the stoma, ties still attached on one side.
Pt desatted, recovered.First thing I saw: trach lying on pillow, stoma open, no air movement felt at stoma. SpO2 on monitor 94% before turn, 81% at 1413, lips dusky.
Called RT and MD.1413 called for help by call light and voice. CNA went for the spare trach and obturator from bedside. 1413 RT M. Cole paged STAT. 1414 inserted spare #6 cuffless trach with obturator, removed obturator, inner cannula in. 1414 bagged via trach, bilateral chest rise, SpO2 89%. 1416 SpO2 95% on 28% trach collar.
MD aware.1418 Dr. A. Patel (hospitalist) notified by phone of dislodgement and reinsertion. Orders: CXR, keep spare trach and obturator at bedside, RT to recheck ties. Read back.

G-tube, found out or pulled during a transfer

How it often gets written How it reads better
Pt pulled out G-tube.0310 on rounds found G-tube lying on bed next to pt, balloon deflated, tip intact. Did not see how it came out. Last seen in place at 0105 during position change.
G-tube reinserted, placement checked, feeding resumed. Tolerated well.Feeding pump stopped at 0310. Site covered with dry gauze. No tube reinserted. 0318 Dr. K. Owens paged, called back 0325. Informed: tube out, time out unknown, up to 2 h 5 min. Order: keep NPO, IR consult in AM, notify if abdominal pain or fever.
Pt resting comfortably.0400 abd soft, nondistended. Pt grimaced on palpation of LUQ near site, which is new compared with 0105. T 37.1, HR 88. Reported grimace to Dr. Owens at 0405.

Chest tube or surgical drain, during a stretcher transfer

How it often gets written How it reads better
Chest tube came out during transfer.1030 sliding pt from bed to stretcher with 3 staff for transport to CT. Chest tube R side, drainage unit on bed rail. I did not have hold of the tubing. During the slide the tubing caught on the bed rail and the tube came out of the insertion site.
Covered site, notified MD, pt stable.1030 first noted: tube tip on sheet, sutures broken, air sound at site. 1031 covered site with gloved hand, then occlusive dressing taped on 3 sides per unit policy. SpO2 97% before move, 92% at 1032, RR 26, pt states it is harder to breathe.
Pt ok.1033 Dr. L. Grant (thoracic) paged, at bedside 1040. CXR ordered STAT. 1050 SpO2 95% on 2 L NC, RR 20. Transport to CT held per Dr. Grant.

ET tube, during a reposition

How it often gets written How it reads better
Pt self-extubated during repositioning.2215 boosting pt up in bed with RN D. Shaw. RT not at bedside. I was holding the ETT at the lip line. On the boost, pt moved head to R, ETT came out. Tube was 23 cm at the lip at 2000 check.
Pt stable on NC.2216 rapid response called. 2216 bagged via mask, SpO2 from 86% to 93%. 2220 RT and Dr. R. Ng at bedside. 2224 Dr. Ng decided not to reintubate, placed on BiPAP. 2240 SpO2 96%, RR 22, pt opens eyes to voice and follows commands.

Template

Chart note: device came out during care

[DATE] [TIME]  Unplanned removal of [DEVICE TYPE AND SIZE, e.g. #6 cuffless trach / 18 Fr G-tube / R chest tube].

Activity at the time: [WHAT YOU WERE DOING, e.g. turning pt to L side for linen change / bed-to-stretcher slide for CT].
Staff present: [NAMES AND ROLES].
Device securement: [WHO WAS HOLDING THE DEVICE, OR NO ONE WAS HOLDING IT]. Ties/sutures/tape: [STATUS BEFORE AND AFTER].
Last confirmed in place: [TIME AND HOW, e.g. 23 cm at lip at 2000 / site checked 0105].

First observed: [EXACTLY WHAT YOU SAW, e.g. trach on pillow, stoma open / tube on sheet, balloon deflated].
Cause witnessed: [YES, DESCRIBE] / [NO, FOUND OUT AT TIME].

Patient before event: SpO2 [ ]%, HR [ ], RR [ ], [COLOR / WORK OF BREATHING / LOC].

Actions, in order:
[TIME]  [ACTION, e.g. called for help by call light and voice]
[TIME]  [ACTION, e.g. RT paged STAT, name]
[TIME]  [ACTION, e.g. spare trach inserted with obturator / site covered with dressing]
[TIME]  [ACTION, e.g. bagged via trach, chest rise bilateral]
[TIME]  [ACTION]

Patient response: [TIME] SpO2 [ ]%, HR [ ], RR [ ], [COLOR / WORK OF BREATHING / LOC].
Patient response: [TIME] SpO2 [ ]%, HR [ ], RR [ ], [COLOR / WORK OF BREATHING / LOC].
Patient communication: [WHAT PT SAID, WROTE, OR SIGNALED, AND WHICH ONE].

Provider notified: [NAME, ROLE] by [PAGE / PHONE / IN PERSON] at [TIME]. Callback or arrival at [TIME].
Information given: [WHAT YOU REPORTED].
Orders received: [ORDERS]. Read back: [YES / NO].
Charge RN notified: [NAME] at [TIME].
Family notified: [NAME, RELATIONSHIP] at [TIME] by [WHO].

Source of times: [MONITOR CLOCK / CODE SHEET / PAGE LOG / ESTIMATED].
Current status: [DEVICE STATUS, PATIENT STATUS, PLAN, NEXT CHECK TIME].
[YOUR NAME, CREDENTIALS]

Message to charge nurse or manager

[DATE] [TIME]
To: [NAME, ROLE]
Re: Unplanned [DEVICE TYPE] removal, room [ROOM], pt [INITIALS OR MRN PER POLICY]

At [TIME], during [ACTIVITY], the patient's [DEVICE] came out.
Staff present: [NAMES AND ROLES]. Holding the device: [NAME OR NO ONE].
Immediate actions: [BRIEF LIST WITH TIMES].
Provider notified: [NAME] at [TIME]. Orders: [ORDERS].
Patient status now: [VITALS AND CONDITION].
Chart note entered at [TIME]. Event report [FILED AT TIME / TO BE FILED BY END OF SHIFT].
Equipment or supply issue noticed: [e.g. no spare trach at bedside / ties worn / NONE].
[YOUR NAME, CREDENTIALS, EXTENSION]

Event report (facts only, no blame, no guessing)

Date and time of event: [DATE] [TIME]
Location: [UNIT, ROOM]
Device: [TYPE, SIZE, DAYS SINCE PLACEMENT IF KNOWN]
Activity at the time: [BATH / TURN / BOOST / TRANSFER / TRANSPORT / OTHER: DESCRIBE]
Staff present and roles: [NAMES AND ROLES]
Who was securing the device: [NAME OR NO ONE]
How the device was secured before the event: [TIES / SUTURE / TAPE / COMMERCIAL HOLDER, CONDITION]
What was observed first: [DESCRIPTION]
Whether the removal itself was witnessed: [YES, BY WHOM / NO]
Sequence of actions with times:
  [TIME] [ACTION]
  [TIME] [ACTION]
  [TIME] [ACTION]
Patient condition before / during / after: [VITALS AND OBSERVATIONS AT EACH POINT]
Notifications: [PROVIDER, TIME, METHOD] / [CHARGE RN, TIME] / [FAMILY, TIME]
Outcome at time of report: [DEVICE STATUS, PATIENT STATUS]
Equipment at bedside at time of event: [SPARE TUBE, OBTURATOR, SUCTION, BAG: PRESENT OR NOT]
Reported by: [YOUR NAME, CREDENTIALS] at [TIME]

Words to avoid

Word or phrase Why it hurts Write instead
pulled out, self-extubatedSays you saw the causefound out at [time], or describe what you saw
tolerated wellNothing you can measure, and later entries may contradict itThe vitals, the exam, what the patient said or did
MD awareNo name, no time, no ordersName, role, how reached, time, orders, read back
stableEvery reader takes it differentlyThe numbers
occluded, blockedCould mean a clot, could mean a tube out of positionSay what you saw: tube out of stoma, unable to pass suction catheter to [cm]
pt statedWrong if the patient wrote it or gesturedpt wrote, pt nodded, family reports
briefly, a few minutesReads as a guessClock times from the monitor or code sheet
accidentallyThat's a conclusion about intentDescribe the movement and who was holding the device

Short summary at shift end leaves gaps

The usual mistake is a short summary written at the end of the shift: trach dislodged during care, replaced, pt tolerated well, MD aware. Every word of it can be true. It still won't answer what people ask later. Who was holding the trach? How long was it out? What did the sats do? Which provider did you tell, and when?

A note like that fails in two ways.

First, it leaves gaps. Gaps get filled from somewhere else: the family's memory, a resident's note, a code sheet, a 911 recording. When those accounts disagree, your note should have been the one that settled it.

Second, it mixes what you saw with what you concluded. Patient pulled out G-tube reads like you watched it happen. If you actually found the tube lying on the bed, the note now claims more than you know. It also suggests a cause (patient behavior), and that can send the next person's thinking the wrong way.

Times are the third weak spot. Write them from memory an hour later and they drift. Say in the note that you checked the monitor clock, or that the times came from the code sheet. That holds up much better than a note where every entry ends in :00 or :30.

Bottom line

Write down what you saw and when you saw it. Leave the cause out unless you watched it happen.

Official guidance

  • When a trach comes out, call for help right away. Keep oxygen going while the tube goes back in. (CION, LifeLogic)
  • Keep a clean spare trach and its obturator at the bedside, so nobody has to go looking for one. (CION, UMass Memorial Health)

In court, 2003–2025

What happened in 5 court cases

Floretta Franklin v. OU Medicine: Supreme Court of Oklahoma, 2025. The patient had a small, pediatric-sized cuffed trach and had just come back from radiology. The court summarized the record like this: "The nurse was turning the patient to the left to clean up a bowel movement and the patient became unresponsive with no palpable pulse." The trach had come out during the turn. Getting a heartbeat back took about seven minutes. The family's petition alleged the nurse did nothing and didn't call for help. The case ended on federal PREP Act immunity, so the court never ruled on the nursing care or the charting. It does show you how the record got used. The hospital's own notes (what the nurse was doing, which way the patient was turned, how long things took) became the factual basis for the opinion.

Cristina Marente v. Eunice Asah and Epic Health Services, Inc.: Court of Criminal Appeals of Texas, 2015. The document we have is the family's brief on appeal. So what follows is their allegation, and no court found it. A home health nurse was bathing a ventilator-dependent teenager and putting him back to bed when the trach came out. She couldn't get it back in. The brief points out that her accounts didn't match: "Nurse Asah has reported at least two different reasons as to how the tracheostomy tube came out." In the 911 call, it came out by accident during the move. In her interrogatory answers, she took it out to change it. When the first written account is vague, people end up comparing the later versions instead.

Jefferson v. Mercy Hospital & Medical Center: Appellate Court of Illinois, 2018. A fresh trach, bleeding at the stoma, and a respiratory arrest overnight. Six later hospital records said a clot in the tube caused the arrest. The ENT's code note said the airway was occluded. At trial he explained that the tube was resting against tissue and "was dislodged rather than blocked." There were more gaps. A resident answered a page and never charted the visit. Another resident wrote down what the family was doing at the trach, then admitted he couldn't actually see it. A nursing entry recorded words the patient stated, but the patient had written them, because the cuffed trach kept her from speaking. The appellate court upheld most of a large jury verdict. Here's what a nurse should take from it: one word like occluded or stated meant one thing to the person who wrote it and something else to every reader after.

People v. Medlin: California Court of Appeal, 2009. At 3 a.m. an LVN found a long-term care resident's G-tube lying on the bed. She didn't know how long it had been out. "She noted in his chart that he had pulled it out forcibly, but she did not see that happen." She reinserted it and checked placement by auscultation only. She couldn't aspirate any gastric contents. She charted that the next feeding was tolerated well. The medication record shows ibuprofen for discomfort after the tube came out and Ativan for anxiety after it went back in. The tube was in the abdominal cavity. The resident died of peritonitis. A jury acquitted both nurses of criminal charges. The appeal was only about whether they were factually innocent, and the court reversed that finding. The charting problems stand on their own. She wrote a cause she didn't witness as fact. And tolerated well sat right next to entries that said otherwise.

Munsen v. Wellmark, Inc.: District Court, N.D. Iowa, 2003. This one is an insurance benefits case. It's here for one fact in the record about a child with subglottic stenosis: if his trach came out, "it must be replaced within approximately one minute". When minutes matter that much, a note that just says trach replaced leaves out the one thing everyone will ask about.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.